A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)
Place client in a negative pressure room
Implement droplet precautions
Encourage the mother to bottle-feed
Give antiviral medication intravenously
Use standard precautions
Correct Answer : C,D,E
A. Place client in a negative pressure room: HIV is not an airborne disease, and clients with HIV do not require isolation in a negative pressure room. Standard precautions are sufficient to prevent transmission.
B. Implement droplet precautions: HIV is not transmitted via droplets. It is transmitted through contact with blood, certain body fluids, or perinatal exposure. Droplet precautions are not indicated.
C. Encourage the mother to bottle-feed: HIV can be transmitted through breast milk. To prevent vertical transmission postpartum, mothers with HIV are advised to avoid breastfeeding and to use formula or bottle-feed instead.
D. Give antiviral medication intravenously: Intrapartum IV zidovudine should be administered in the following situations: (a) HIV RNA >1,000 copies/mL, (b) unknown HIV RNA, (c) known or suspected lack of adherence since the last HIV RNA result, or (d) a positive expedited antigen/antibody HIV test result during labor (AI).
E. Use standard precautions: Standard precautions are the appropriate infection control measures for caring for clients with HIV. This includes wearing gloves, practicing proper hand hygiene, and avoiding contact with the client's blood and other potentially infectious fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Obtain a drug screen for cocaine: Given the symptoms described (tremulous, tachycardic, hypertensive), there may be concern about drug exposure, and cocaine is a substance known to cause such symptoms in newborns. Therefore, obtaining a drug screen for cocaine is a reasonable and important action to determine if there was prenatal exposure.
B. Weigh and measure the newborn: While weighing and measuring the newborn is a routine part of the newborn assessment, it may not be the most crucial action in this context. The symptoms described suggest the need for a more immediate assessment related to possible drug exposure.
C. Determine reactivity of neonatal reflexes: Assessing the reactivity of neonatal reflexes is an important part of the newborn assessment, but in this specific situation, the symptoms described (tremulous, tachycardic, hypertensive) may warrant a more focused and immediate assessment related to drug exposure.
D. Perform gestational age assessment: Gestational age assessment is essential for understanding the newborn's maturity and adjusting care accordingly. However, in this scenario, the immediate concern seems to be the symptoms the newborn is presenting with, and addressing the possibility of drug exposure takes precedence.
Correct Answer is A
Explanation
A. Flaring of the nares:
Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.
B. Shallow and irregular respirations:
Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.
C. Respiratory rate of 50 breaths per minute:
While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.
D. Abdominal breathing with synchronous chest movement:
Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.
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